If something happens to which you automatically and reflexively react with fear or anxiety, your thoughts will tend to be about danger and the consequences of being harmed. Similarly, if your instant reaction to an event is to feel angry or sad or happy ? and especially if you also act on your feelings ? your thoughts (including your recollections of the past and your vision of the future) will be biased in the same direction
Emotional reactions arise chiefly in a region of the brain called the limbic system, which is very fast-acting and can respond to events on the basis of quick-and-dirty impressions. This nimbleness of response has survival value in some situations ? such as noticing a fast-moving object that could be a car or truck approaching as you cross a street.
But on other occasions ? such as complex situations where you need to call on more of your accumulated knowledge and experience, speed can be a disadvantage. The more complete information you need at such times has to be processed by the lateral prefrontal cortex of your brain ? which gets into gear about half a second later than your limbic system. This short delay is often enough that your thinking, under the influence of an automated emotional reaction, heads off in a biased direction that you may come to regret.
In instances like these, the influence of thinking on emotions can be one of sustaining or amplifying an emotion as opposed to initiating it. (To see how this works, remember some occasion when something made you hopping mad, and you then fed the feeling with minutes or hours of angry thoughts ? only to discover later on that there had simply been a misunderstanding.)
In practice, treating this kind of problem clinically involves methods traditionally associated, not with cognitive therapy, but with behavior therapy. To which we now turn.
The behavioral side of CBT
You've probably heard about the Russian physiologist Ivan Pavlov. The one who taught dogs to salivate when they heard a buzzer. Since we're going to be talking about Pavlov's contributions to psychotherapy, you may as well know that he looked exactly like this guy with the cool Edwardian beard . . . .
Much, though far from all, of behavior therapy derives from Pavlov's demonstration that events occurring closely together in time are likely to be stored in the brain in a sort of mental package. Because Pavlov set off the buzzer just as he was about to give the dog some food, the buzzer and the food became associated with each other. As a result, after a while the dog began salivating when he heard a buzzer ? whether he was given food or not.
The next thing Pavlov discovered was that if he sounded the buzzer too often without coming through with some food, the dog no longer salivated just because there was a buzzer buzzing. In behavior jargon, this is called ?extinction.? It refers to the fact that a conditioned reaction ? in humans as well as dogs ? can become substantially overridden if it is no longer "reinforced."
(Reinforcement, in the Pavlovian learning model, means that some event like the sounding of a buzzer ? which doesn't naturally bring forth a reaction such as a salivating ? is experienced at the same time as something that does, such as the sight or smell of food. When this happens, the event can become an artificial cue or signal that triggers something resembling the natural response.)
P.S.: Recent developments in learning theory ? corroborated by recordings of dopamine-connected neurons of the brain's ?reward system? ? suggest that Pavlov's dogs didn't learn to salivate just because they heard the buzzer at the same time as they received food. They learned it when the arrival of food came as something of a surprise, since they hadn't previously expected buzzers to be a signal for food. Makes sense: if they'd already known about the connection, what would there have been for them to learn?
A couple of practical examples
For example, if you are deathly afraid of riding in elevators, we can usually extinguish that fear if you are willing to crank up your courage and take one elevator ride after another until you are no longer unreasonably afraid. It works because your conditioned fear reaction is not being reinforced ? that is, the elevator doesn't fall or get stuck for hours.
(On the other hand, if you give in to the fear and avoid elevators, you can pretty much count on spending the rest of your life being afraid of them.)
Or, to give another example, let's imagine that you become depressed following a setback such as the loss of a loved one or the collapse of your efforts to achieve some valued goal.
You may feel that it's useless to try to live a normal life, since your energy and ability to enjoy things seem to have vanished. You probably expect that pursuing your goals will merely lead to disappointment, frustration or failure ? in other words, you have a sense of futility. Acting on these feelings, you drop out of your usual activities and social relations. The result: your life becomes even more constricted and unrewarding, and your morale goes still deeper into the hole.
Getting back to normal
What we are likely to do in CBT is move you gradually back towards leading a normal life, without waiting for it to feel as good as it once did. If you diligently follow this plan, the renewed contact with your friends, family and regular activities should eventually bring your mood and feelings back to normal. This is because before you became depressed, your usual activities and relationships were associated with more energy and enjoyment than you are feeling now. We are trying to take advantage of those connections as a means of bootstrapping your morale to a more satisfactory level.
(You might like to see the report of a 1996 study of treatment for depression suggesting that this kind of behavioral intervention may be as effective as full-scale cognitive behavior therapy for depression.)
Other behavioral aspects of CBT have nothing to do with Pavlov or "conditioning" of any kind. For instance, we often work with patients to experiment with taking some action that is likely to prove beneficial and instructive. Or, right in the office, to enact (rather than just talk about) an interpersonal or internal conflict, in the manner of Gestalt therapy "chair work" or psychodrama.
These have been just a few illustrations of the hundreds of behavioral interventions that are possible. But perhaps now you have at least some feel for the ?B? in CBT.
Why cognitive? Why behavioral?
Everyone, including cognitive behavior therapists, understands that emotions and moods are governed by factors in addition to one's own thinking and behavior. However, as a practical matter virtually the only means of access to our moods and emotions are the cognitive and behavioral routes.
In order to voluntarily change how we feel, we have to go about it indirectly, not directly. There is no direct way to influence our feelings and moods. Brains simply aren't built so as to make this possible.
Now, according to Prof. James Gross of Stanford, a leading researcher in the field of emotion regulation, there are five points in the generation of an emotion at which it may be possible to exercise deliberate influence:
selection of the situation
modification of the situation
deployment of attention
change of cognitions
modulation of responses
The first, second and fifth of these points are targeted in behavior therapy, the third and fourth in cognitive therapy. As you no doubt suspect, most of the time some combination of behavioral and cognitive methods is needed.
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